Building a maternal and child cohort amidst Lebanon's socioeconomic collapse: preliminary results and navigating research challenges

The impact of conflict and crisis on maternal and child health underscores the need for reliable research in vulnerable populations. Lebanon, amidst ongoing economic collapse, political instability, and healthcare system strain, offers a case study for exploring these impacts, particularly on preterm babies and their development. This study aims to assess the feasibility of establishing a prospective cohort of mothers and their full-term and preterm babies in Lebanon, examining the association between social determinants, preterm birth, and developmental outcomes amidst the nation's multifaceted crises. The planned cohort involves 50 full-term and 50 preterm mother-baby pairs recruited at birth and followed up to 9-12 months post-birth. Data collection spans social determinants, perceived stress, social support, quality of life, and developmental assessments. Challenges in recruitment, follow-up, and data collection in the context of Lebanon's socio-political and economic turmoil are evaluated, alongside ethical considerations for research in vulnerable populations. Preliminary findings highlight substantial recruitment and follow-up challenges, notably due to population mobility, economic instability, and healthcare access issues. Despite these obstacles, 113 mother-baby pairs have been recruited. Early analysis reveals significant stress and reduced quality of life among mothers, particularly those with preterm infants, against a backdrop of declining birth rates and healthcare worker exodus. Conducting research in crisis settings like Lebanon presents unique methodological and ethical challenges but remains crucial for understanding and improving health outcomes in vulnerable populations. The study underscores the importance of adaptable research designs and ethical diligence in crisis research, highlighting the need for interventions tailored to these contexts. Establishing a mother and child cohort in Lebanon's crisis-ridden setting is faced with many challenges but is essential for guiding future interventions. Research in such contexts is needed to address health disparities and supporting vulnerable populations, emphasizing the need for dedicated funding and innovative research approaches in times of crisis.

Corneal confocal microscopy demonstrates varying degrees of neurodegeneration in atypical parkinsonian disorders

OBJECTIVE

We have used corneal confocal microscopy (CCM) to identify corneal nerve loss as a potential marker of neurodegeneration in participants with Parkinson's disease (PD), multiple system atrophy (MSA) and progressive supranuclear palsy (PSP).

METHODS

Patients with PD (n = 19), PSP (n = 11), MSA (n = 8) and healthy controls (n = 18) underwent neurological assessment and CCM.

RESULTS

Corneal nerve fibre density was significantly lower in participants with PD (p = 0.005), PSP (p = 0.005) and MSA (p = 0.0003) compared to controls. Corneal nerve branch density was significantly lower in participants with PD (p = 0.01) and MSA (p = 0.019), but not in participants with PSP (p = 0.662), compared to controls. Corneal nerve fibre length was significantly lower in participants with PD (p = 0.002) and MSA (p = 0.001) but not in participants with PSP (p = 0.191) compared to controls.

CONCLUSION

CCM detects corneal nerve loss in participants with PD and MSA and to a lesser extent in PSP compared to healthy controls.

Corneal immune cells as a biomarker of inflammation in multiple sclerosis: a longitudinal study

Background

Corneal immune cells (ICs) are antigen-presenting cells that are known to increase ocular and systemic inflammatory conditions.

Objective

We aimed to assess longitudinal changes in corneal IC in patients with multiple sclerosis (MS) and relation to disability and ongoing treatment.

Design

Prospective observational study conducted between September 2016 and February 2020.

Methods

Patients with relapsing-remitting MS (RRMS) (n = 45) or secondary progressive MS (SPMS) (n = 15) underwent corneal confocal microscopy (CCM) at baseline and 2-year follow-up for estimation of corneal IC density [dendritic cells with (DCF) (cells/mm2) or without nerve fiber contact (DCP); and non-dendritic cells with (NCF) or without nerve fiber contact (NCP)]. Optical coherence tomography, neuroimaging, and disability assessments were additionally performed. Healthy controls (n = 20) were assessed at baseline.

Results

In both RRMS and SPMS compared to controls, DCP (p < 0.001 and p < 0.001, respectively) and DCF (p < 0.001 and p = 0.005) were higher and NCF (p = 0.007 and p = 0.02) was lower at baseline. DCP showed excellent performance in identifying patients with MS (sensitivity/specificity = 0.88/0.90) followed by DCF (0.80/0.75) and NCF (0.80/0.85). At follow-up compared to baseline, DCP (p = 0.01) was significantly reduced, and NCP (p = 0.004) and NCF (p = 0.04) were increased. Subgroup analysis showed that baseline NCP and NCF were significantly higher (p = 0.04-0.05) in patients who switched disease-modifying treatment, and baseline NCP (p = 0.05) was higher in patients on interferon.

Conclusion

Baseline and change in corneal IC were related to axonal degeneration and treatment status. Evaluation of corneal IC using CCM may allow an assessment of ongoing inflammation, disease progression, and the effect of treatment in MS.

Corneal nerve loss predicts dementia in patients with mild cognitive impairment

OBJECTIVES

This study compared the utility of corneal nerve measures with brain volumetry for predicting progression to dementia in individuals with mild cognitive impairment (MCI).

METHODS

Participants with no cognitive impairment (NCI) and MCI underwent assessment of cognitive function, brain volumetry of thirteen brain structures, including the hippocampus and corneal confocal microscopy (CCM). Participants with MCI were followed up in the clinic to identify progression to dementia.

RESULTS

Of 107 participants with MCI aged 68.4 ± 7.7 years, 33 (30.8%) progressed to dementia over 2.6-years of follow-up. Compared to participants with NCI (n = 12), participants who remained with MCI (n = 74) or progressed to dementia had lower corneal nerve measures (p < 0.0001). Progressors had lower corneal nerve measures, hippocampal, and whole brain volume (all p < 0.0001). However, CCM had a higher prognostic accuracy (72%-75% vs 68%-69%) for identifying individuals who progressed to dementia compared to hippocampus and whole brain volume. The adjusted odds ratio for progression to dementia was 6.1 (95% CI: 1.6-23.8) and 4.1 (95% CI: 1.2-14.2) higher with abnormal CCM measures, but was not significant for abnormal brain volume.

INTERPRETATION

Abnormal CCM measures have a higher prognostic accuracy than brain volumetry for predicting progression from MCI to dementia. Further work is required to validate the predictive ability of CCM compared to other established biomarkers of dementia.

Corneal axonal loss as an imaging biomarker of neurodegeneration in multiple sclerosis: a longitudinal study

Background

Resourceful endpoints of axonal loss are needed to predict the course of multiple sclerosis (MS). Corneal confocal microscopy (CCM) can detect axonal loss in patients with clinically isolated syndrome and established MS, which relates to neurological disability.

Objective

To assess corneal axonal loss over time in relation to retinal atrophy, and neurological and radiological abnormalities in MS.

Methods

Patients with relapsing-remitting (RRMS) (n = 68) or secondary progressive MS (SPMS) (n = 15) underwent CCM and optical coherence tomography. Corneal nerve fibre density (CNFD-fibres/mm²), corneal nerve branch density (CNBD-branches/mm²), corneal nerve fibre length (CNFL-mm/mm²) and retinal nerve fibre layer (RNFL-μm) thickness were quantified along with neurological and radiological assessments at baseline and after 2 years of follow-up. Age-matched, healthy controls (n = 20) were also assessed.

Results

In patients with RRMS compared with controls at baseline, CNFD (p = 0.004) and RNFL thickness (p < 0.001) were lower, and CNBD (p = 0.003) was higher. In patients with SPMS compared with controls, CNFD (p < 0.001), CNFL (p = 0.04) and RNFL thickness (p < 0.001) were lower. For identifying RRMS, CNBD had the highest area under the receiver operating characteristic (AUROC) curve (0.99); and for SPMS, CNFD had the highest AUROC (0.95). At follow-up, there was a further significant decrease in CNFD (p = 0.04), CNBD (p = 0.001), CNFL (p = 0.008) and RNFL (p = 0.002) in RRMS; in CNFD (p = 0.04) and CNBD (p = 0.002) in SPMS; and in CNBD (p = 0.01) in SPMS compared with RRMS. Follow-up corneal nerve loss was greater in patients with new enhancing lesions and optic neuritis history.

Conclusion

Progressive corneal and retinal axonal loss was identified in patients with MS, especially those with more active disease. CCM may serve as an imaging biomarker of axonal loss in MS.

Muslim women's attitudes toward infant feeding in Qatar: An exploration using the Iowa infant feeding attitude scale

BACKGROUND

Maternal attitude toward infant feeding is an important determinant of breastfeeding. The Islamic faith encourages breastfeeding, yet many Muslim women do not breastfeed as per the World Health Organization recommendations. In the Middle East, research has not addressed attitudes toward infant feeding among Muslim women. Assessing women's attitudes toward infant feeding choices is crucial to improve breastfeeding rates among Muslim women.

AIM

The aims of this study are to (a) examine postpartum Muslim women's attitudes toward infant feeding, (b) identify the determinants of these attitudes, and (c) determine whether attitudes can predict breastfeeding intention among Muslim women. A secondary aim is to examine the psychometric attributes of the Iowa Infant Feeding Attitude Scale among Muslim women.

METHOD

A convenience sample of postpartum Muslim women (N = 414) were recruited between November 2019 and January 2020 in a large maternity facility in Qatar. A pre-developed questionnaire and the IIFAS were used to collect data. Both Arabic (n = 228) and English (n = 186) versions of the IIFAS were distributed postnatally to measure Muslim women's attitudes towards breastfeeding. A total attitude score was computed with higher scores indicating a more positive attitude toward breastfeeding.

FINDINGS

The mean age of participants was 30.3 ± 5.2 years; 65.2% had a university degree and only 20.5% were employed. The mean attitude score was 61.8 ± 7.8. A significant association was found between the IIFAS attitude score and ethnicity, favouring Non-Qatari Arab women who had significantly higher attitude scores (p < .001). Women with full-time or part-time work had significantly higher scores than those not working (p = .008, p = .023). Older women had significantly lower attitude scores (adjusted slope = -0.230, p = .008). Cronbach's alpha reliability coefficient of the Arabic and English versions of the IIFAS ranged from 0.69 to 0.80.

CONCLUSION

Ethnicity, employment status, and age are determinants of infant feeding attitudes among Muslim women. In Qatar, Muslim women's attitudes related to breastfeeding trend toward positive; however, attitude is not a predictor of antenatal breastfeeding intention. Further research employing a larger sample with a focus on a culturally sensitive approach is recommended. The IIFAS has a moderate reliability level and needs to be culturally adapted to be used among a Muslim population.

Progressive loss of corneal nerve fibers is associated with physical inactivity and glucose lowering medication associated with weight gain in type 2 diabetes

Aims/Introduction

Limited studies have identified risk factors linked to the progression of diabetic peripheral neuropathy (DPN) in type 2 diabetes. This study examined the association of risk factors with change in neuropathy measures over 2 years.

Materials and Methods

Participants with type 2 diabetes (n = 78) and controls (n = 26) underwent assessment of clinical and metabolic parameters and neuropathy using corneal confocal microscopy (CCM), vibration perception threshold (VPT), and the DN4 questionnaire at baseline and 2 year follow‐up.

Results

Participants with type 2 diabetes had a lower corneal nerve fiber density (CNFD), branch density (CNBD), and fiber length (CNFL) (P ≤ 0.0001) and a higher VPT (P ≤ 0.01) compared with controls. Over 2 years, despite a modest reduction in HbA1c (P ≤ 0.001), body weight (P ≤ 0.05), and LDL (P ≤ 0.05) the prevalence of DPN (P = 0.28) and painful DPN (P = 0.21) did not change, but there was a significant further reduction in CNBD (P ≤ 0.0001) and CNFL (P ≤ 0.05). CNFD, CNBD, and CNFL decreased significantly in physically inactive subjects (P < 0.05–0.0001), whilst there was no change in CNFD (P = 0.07) or CNFL (P = 0.85) in physically active subjects. Furthermore, there was no change in CNFD (P = 0.82), CNBD (P = 0.08), or CNFL (P = 0.66) in patients treated with glucose lowering medication associated with weight loss, whilst CNBD (P = 0.001) decreased in patients on glucose lowering medication associated with weight gain.

Conclusions

In participants with type 2 diabetes, despite a modest improvement in HbA1c, body weight, and LDL there was a progressive loss of corneal nerve fibers; except in those who were physically active or on glucose lowering medication associated with weight loss.

The Impact of the COVID-19 Lockdown “Home Quarantine” on the Physical Activity and Lifestyle of Children in Qatar

Background

Several studies have investigated how the coronavirus disease 2019 (COVID-19) pandemic impacted children's lifestyle. To our knowledge, this is the first study that assesses the impact of quarantine on physical activity, screen time, sleep, and diet in children aged 5 to 12 in Qatar.

Methods

Cross-sectional data from an online survey distributed in Qatar was analyzed. The survey measured the parents' or caregivers' assessment on the change in the child's physical activity, sleep, screen time, and diet between the two periods (before quarantine and during quarantine). The data was analyzed using frequency distributions, paired t-test and McNemar's test.

Results

Data from 144 respondents were analyzed. Due to the quarantine, the total weekly average hours of physical activity significantly decreased with a greatest reduction for the school and after school durations. Only 4.5% of the children were engaging in at least 60 minutes of physical activity per day (in contrast to 25.6% prior to quarantine). The reported barriers for physical activity were screen time for school (52.8%) and leisure (51.4%). There was a significant increase in the total number of main meals per day, with a higher consumption of unhealthy food. The majority of the children had their bedtime and waketime shifted to later because of the quarantine. The parents' or caregivers' satisfaction with the child's lifestyle during quarantine showed that 49.1% were disappointed or very disappointed. Also, 53.8% described their child's mental health as “better before quarantine.”

Conclusions

Quarantine had a negative impact on the lifestyle of children in Qatar. When implementing restrictions, authorities should consider some interventions to counterpart such impact.

Prevalence and risk factors for diabetic peripheral neuropathy, neuropathic pain and foot ulceration in the Arabian Gulf Region

Aims/Introduction

This study determined the prevalence and risk factors for diabetic peripheral neuropathy (DPN), painful DPN and diabetic foot ulceration (DFU) in patients with type 2 diabetes in secondary healthcare in Qatar, Kuwait and the Kingdom of Saudi Arabia.

Materials and Methods

Adults aged 18–85 years with type 2 diabetes were randomly enrolled from secondary healthcare, and underwent clinical and metabolic assessment. DPN was evaluated using vibration perception threshold and neuropathic symptoms and painful Diabetic Peripheral Neuropathy was evaluated using the Douleur Neuropathique 4 questionnaire.

Results

A total of 3,021 individuals were recruited between June 2017 and May 2019. The prevalence of DPN was 33.3%, of whom 52.2% were at risk of DFU and 53.6% were undiagnosed. The prevalence of painful DPN was 43.3%, of whom 54.3% were undiagnosed. DFU was present in 2.9%. The adjusted odds ratios for DPN and painful DPN were higher with increasing diabetes duration, obesity, poor glycemic control and hyperlipidemia, and lower with greater physical activity. The adjusted odds ratio for DFU was higher with the presence of DPN, severe loss of vibration perception, hypertension and vitamin D deficiency.

Conclusions

This is the largest study to date from the Middle East showing a high prevalence of undiagnosed DPN, painful DPN and those at risk of DFU in patients with type 2 diabetes, and identifies their respective risk factors.

Dimensional (premenstrual symptoms screening tool) vs categorical (mini diagnostic interview, module U) for assessment of premenstrual disorders

BACKGROUND

Premenstrual syndrome (PMS) is the constellation of physical and psychological symptoms before menstruation. Premenstrual dysphoric disorder (PMDD) is a severe form of PMS with more depressive and anxiety symptoms. The Mini international neuropsychiatric interview, module U (MINI-U), assesses the diagnostic criteria for probable PMDD. The Premenstrual Symptoms screening tool (PSST) measures the severity of these symptoms.

AIM

To compare the PSST ordinal scores with the corresponding dichotomous MINI-U answers.

METHODS

Arab women (n = 194) residing in Doha, Qatar, received the MINI-U and PSST. Receiver Operating Characteristics (ROC) analyses provided the cut-off scores on the PSST using MINI-U as a gold standard.

RESULTS

All PSST ratings were higher in participants with positive responses on MINI-U. In addition, ROC analyses showed that all areas under the curves were significant with the cutoff scores on PSST.

CONCLUSION

This study confirms that the severity measures from PSST can recognize patients with moderate/ severe PMS and PMDD who would benefit from immediate treatment.

Assessment of an intensive education program for pharmacists on treatment of tobacco use disorder using an objective structured clinical examination: a randomized controlled trial

BACKGROUND

Tobacco use is one of the major public health threats globally. Community pharmacists are uniquely positioned to offer tobacco cessation services owing to their easy accessibility by the public. To prepare Qatar community pharmacists to develop the competencies and skills required to offer smoking cessation services, an intensive tobacco control education program was designed and implemented. The study aimed to assess the impact of the tobacco education program on the pharmacists' skills and competence.

METHODS

A random sample of community pharmacists in Qatar was chosen for participation in the program. Consenting participants were randomly assigned to either intervention or control groups. The intervention group received an intensive education program on treatment of tobacco-use disorder, while a short didactic session on a non-tobacco-related topic was delivered to the control group. The pharmacists' tobacco cessation skills and competencies were assessed using an Objective Structured Clinical Examination (OSCE).

RESULTS

A total of 54 and 32 community pharmacists in the intervention group and the control group, respectively, completed the OSCE. The intensive tobacco education group achieved significantly higher total scores than the control group in all the OSCE cases. Specifically, the mean total scores for the intervention group were 15.2, 15.3, 14.2, 14.6, 16.3, and 15.2 compared to 8.8, 6.2, 7.7, 9.2, 8.3, and 11.3 for the control group (p < 0.001) for cases one to six respectively.

CONCLUSION

The study demonstrated that an intensive tobacco cessation education program can improve pharmacists' tobacco cessation skills and increase their tobacco cessation counseling abilities.

TRIAL REGISTRATION

Clinical Trials NCT03518476 ( https://clinicaltrials.gov/ct2/show/NCT03518476 ) Registration date: May 8, 2018.

Effect of high dose vitamin D supplementation on indices of sarcopenia and obesity assessed by DXA among older adults: A randomized controlled trial

BACKGROUND

Hypovitaminosis D is associated with Sarcopenic Obesity (SO), but evidence from randomized Vitamin D 3 (VD3) trials is scarce.

OBJECTIVE

Compare the effect of VD3 supplementation, at two doses, on SO indices at 12 months.

METHODS

Overweight older adults (>65 years) with baseline 25-hydroxyvitamin D (25OHD) of 10-30 ng/mL were recruited in this double-blind, randomized, controlled multicenter trial (clinicaltrial.gov identifier: NCT01315366). All subjects received 1000 mg calcium citrate/day and underwent total body Dual-energy X-ray Absorptiometry for body composition assessment. Low Dose Group (LDG) and High Dose Group (HDG) received 600 IU -Institute of Medicine (IOM) Recommended Dietary Allowance (RDA)- and 3750 IU VD3/day, respectively.

RESULTS

Mean age was 71 ± 4.6 years, 55% females, BMI: 30.2 ± 4.5 Kg/m², and 43% had metabolic syndrome. There were no differences in baseline characteristics between groups. At 12 months, 248 participants had body composition data, 122 in LDG and 126 in HDG. Proportions of patients with diminished muscle mass, muscle strength, and visceral adiposity did not differ between the 2 groups at baseline or 12 months. Similarly, no significant differences were noted in the proportion of patients with SO at study entry (1.8% in LDG vs 1.6% HDG; p = 0.99) and at 12 months (3.7% in LDG vs. 0.9% HDG; p = 0.18) across arms.

CONCLUSIONS

Weekly VD3, at the daily equivalent of 3750 IU/day, did not improve indices of sarcopenia nor adiposity compared to the IOM RDA dose in adults.

Healthcare Professionals' Attitudes Toward Patients With Mental Illness: A Cross-Sectional Study in Qatar

BACKGROUND

Negative attitudes toward mental illness by Health Care Professionals (HCP) have been reported in many countries across the world. Stigmatizing attitudes by HCP can have adverse consequences on people with mental illness from delays in seeking help to decreased quality of care provided. Assessing such attitudes is an essential step in understanding such stigma and, if needed, developing and testing appropriate and culturally adapted interventions to reduce it.

AIMS

To assess physicians and nurses attitudes toward mental illness and to determine associated factors with different levels of stigma.

METHODS

A cross-sectional survey was conducted among Physicians and Nurses. The Mental Illness Clinician's Attitudes (MICA) scale was used to assess attitudes toward mental illness. MICA scores range between 1 and 6 with higher values indicating higher stigmatizing attitudes. Demographic and work related information were also gathered. Descriptive statistics along with multivariate linear and multivariate logistic regression models were used.

RESULTS

A total of 406 nurses and 92 doctors participated in the study. The nurses' mean MICA score was significantly higher than that of the physicians. Among nurses, being Asian and working in a geriatric, rehabilitation and long-term care facility were associated with lower MICA scores. Among physicians, being female or graduating more than 1 year ago were also associated with lower MICA scores.

CONCLUSION

Stigmatizing attitudes toward people with mental illness by healthcare workers are present in Qatar. They are higher among nurses as compared to physicians. Factors associated with higher stigmatizing attitudes could be used in creating appropriate intervention to reduce the magnitude of the problem.

Factors associated with suicidality among school attending adolescents in morocco

Suicide amongst adolescents is a growing epidemic accounting for 6% of all adolescent deaths. Even though 79% of adolescent suicides occur in low- and middle-income countries, where suicide is the second leading cause of death, research is relatively lacking. As such, we aim to gain a greater understanding of suicide in said countries by assessing ideation and planning and associated factors in Morocco. Global Schools Health Survey data was analyzed. Approximately 14.4 and 12.9% reported ideation and planning respectively during the prior year in 2016, indicating a decrease from the reported rates of ideation of 16.0 and 17.0% and planning of 14.6 and 15.0% in 2006 and 2010 surveys respectively. Increased ideation was found to be positively associated with identifying as female and increasing age, whereas planning was positively associated with a lower educational level and living in a rural area. Both were positively associated with increased hunger frequency. Several factors increased the likelihood of ideation: bullying, feeling lonely, current cigarettes smoking, and current marijuana use. Studying factors associated with suicide is challenging, alternatively, factors affecting ideation and planning can be assessed. Sociocultural differences may impact trends in a specific region, though countries in said region may have comparable trends. The study adds to the limited data available in the region. Reverse causality and under-reporting could be the main limitations of this study. Interventions taking into account those results should be tested to decrease such a prevalence.

Loss of corneal nerves and brain volume in mild cognitive impairment and dementia

Introduction

This study compared the capability of corneal confocal microscopy (CCM) with magnetic resonance imaging (MRI) brain volumetry for the diagnosis of mild cognitive impairment (MCI) and dementia.

Methods

In this cross‐sectional study, participants with no cognitive impairment (NCI), MCI, and dementia underwent assessment of Montreal Cognitive Assessment (MoCA), MRI brain volumetry, and CCM.

Results

Two hundred eight participants with NCI (n = 42), MCI (n = 98), and dementia (n = 68) of comparable age and gender were studied. For MCI, the area under the curve (AUC) of CCM (76% to 81%), was higher than brain volumetry (52% to 70%). For dementia, the AUC of CCM (77% to 85%), was comparable to brain volumetry (69% to 93%). Corneal nerve fiber density, length, branch density, whole brain, hippocampus, cortical gray matter, thalamus, amygdala, and ventricle volumes were associated with cognitive impairment after adjustment for confounders (All P’s < .01).

Discussion

The diagnostic capability of CCM compared to brain volumetry is higher for identifying MCI and comparable for dementia, and abnormalities in both modalities are associated with cognitive impairment.

Effect of Reperfusion Therapies on Incidence of Early Post-Stroke Seizures

Objective: This study aimed to determine the effect of reperfusion therapies on the occurrence of early post-stroke seizures (PSS) in patients with acute ischemic stroke (AIS). Background: Reperfusion therapies are paramount to the treatment of stroke in the acute phase. However, their effect on the incidence of early seizures after an AIS remains unclear. Design and Methods: The stroke database at Hamad Medical Corporation was used to identify all patients who received reperfusion therapies for AIS from 2016 to 2019. They were matched with patients of similar diagnosis, gender, age, and stroke severity as measured by National Institutes of Health Stroke Scale (NIHSS) who did not receive such treatment. The rates of early PSS were calculated for each group. Results: The results showed that 508 patients received reperfusion therapies (342 had IV thrombolysis only, 70 had thrombectomies only, and 96 had received both), compared with 501 matched patients receiving standard stroke unit care. Patients who received reperfusion therapies were similar to their matched controls for mean admission NIHSS score (9.87 vs. 9.79; p = 0.831), mean age (53.3 vs. 53.2 years; p = 0.849), and gender distribution (85 vs. 86% men; p = 0.655). The group receiving reperfusion therapies was found to have increased stroke cortical involvement (62 vs. 49.3%, p < 0.001) and hemorrhagic transformation rates (33.5 vs. 18.6%, p < 0.001) compared with the control group. The rate of early PSS was significantly lower in patients who received reperfusion therapies compared with those who did not (3.1 vs. 5.8%, respectively; p = 0.042). When we excluded seizures occurring at stroke onset prior to any potential treatment implementation, the difference in early PSS rates between the two groups was no longer significant (2.6 vs. 3.9%, respectively; p = 0.251). There was no significant difference in early PSS rate based on the type of reperfusion therapy either (3.2% with thrombolysis, 2.9% with thrombectomy, and 3.1% for the combined treatment, p = 0.309). Conclusions: Treatment of AIS with either thrombectomy, thrombolysis, or both does not increase the risk of early PSS.

Point-of-care ultrasound to confirm endotracheal tube cuff position in relationship to the cricoid in the pediatric population

BACKGROUND

Anatomically, the subglottic area and the cricoid ring are the narrowest portions of the larynx. To limit the potential for damage related to mucosal pressure injuries from the presence of an endotracheal tube, the cuff should be placed below the cricoid in children. Previously, no clinical or imaging method has been used in real time to determine the exact location of the endotracheal tube cuff after endotracheal intubation. Point-of-care ultrasound may provide an option as a safe and rapid means of visualizing the endotracheal tube cuff and its relationship to the cricoid ring thereby achieving ideal endotracheal tube cuff positioning-below the cricoid.

METHODS

In this prospective, nonrandomized trial, point-of-care ultrasound was used following endotracheal intubation in children to evaluate the position of the endotracheal tube cuff in relationship to the cricoid and tracheal rings. After anesthesia was induced and the trachea was intubated, the endotracheal tube cuff and its position in relation to the cricoid and tracheal rings were identified in the longitudinal plane using point-of-care ultrasound. With the patient's neck in a neutral position, the level of the proximal (cephalad) margin of the saline-filled cuff of the endotracheal tube was identified and recorded in relationship to the cricoid and tracheal rings. The ideal position is defined as the cephalad margin of the endotracheal tube cuff below the level of the cricoid.

RESULTS

The study cohort included 80 patients, ranging in age from 1 to 78 months. In all patients, the cuff of the ETT, cricoid, and tracheal rings were identified. The cephalad end of the endotracheal tube cuff was found at the level of the cricoid in 16.3% of patients, at the first tracheal ring in 27.5% of patients, at the second tracheal ring in 23.8% of patients, at the third tracheal ring in 17.5% of patients, and at below the fourth tracheal ring in 15% of patients. Initial endotracheal tube cuff position had no significant association with age, height, weight, endotracheal tube size, and endotracheal tube type.

CONCLUSION

Point-of-care ultrasound provides a rapid and effective means of identifying the position of the endotracheal tube cuff in relationship to the cricoid ring. The technique may have applications in the perioperative arena, emergency departments, and intensive care units.

The association of parental involvement with adolescents' well-being in Oman: evidence from the 2015 Global School Health Survey

BACKGROUND

The parent-adolescent relationship plays a key role in adolescent development, including behaviour, physical health, and mental health outcomes. Studies on the parental factors that contribute to an adolescent's dietary habits, exercise, mental health, physical harm and substance use are limited in the Middle East and North Africa region, with none in Oman. This study aims to investigate the association between parental involvement and adolescent well-being in Oman.

METHODS

Cross-sectional data from the 2015 Global School Health Survey for Oman was analysed. The dataset consisted of 3468 adolescents. Adolescents reported on their parental involvement (checking to see if they did their homework, understanding their problems, knowing what they are doing in their free time and not going through their things without permission). Parental involvement was scored on a 20-point scale. Associations with the following dependent variables: nutrition, exercise, hygiene, physical harm, bullying, substance use, tobacco use and mental health well-being were done using Spearman's correlations, linear and logistic regressions.

RESULTS

The surveyed population was 48% male, 65% aged 15 to 17 years old and 5% reported that they "most of the time or always" went hungry. Parental involvement was positively correlated with each of the dependent variables. Adolescents with higher parental involvement had significantly higher odds of good nutrition (1.391), hygiene (1.823) and exercise (1.531) and lower odds of physical harm (0.648), being bullied (0.628), poor mental health (0.415), tobacco use (0.496) and substance use (0.229).

CONCLUSIONS

Parental involvement plays a positive role in all aspects of adolescents' well-being in Oman. Awareness campaigns and interventions aimed to help improve the well-being of adolescents should incorporate such positive role in their designs.

Corneal Nerve and Brain Imaging in Mild Cognitive Impairment and Dementia

Background:

Visual rating of medial temporal lobe atrophy (MTA) is an accepted structural neuroimaging marker of Alzheimer’s disease. Corneal confocal microscopy (CCM) is a non-invasive ophthalmic technique that detects neuronal loss in peripheral and central neurodegenerative disorders.

Objective:

To determine the diagnostic accuracy of CCM for mild cognitive impairment (MCI) and dementia compared to medial temporal lobe atrophy (MTA) rating on MRI.

Methods:

Subjects aged 60–85 with no cognitive impairment (NCI), MCI, and dementia based on the ICD-10 criteria were recruited. Subjects underwent cognitive screening, CCM, and MTA rating on MRI.

Results:

182 subjects with NCI (n = 36), MCI (n = 80), and dementia (n = 66), including AD (n = 19, 28.8%), VaD (n = 13, 19.7%), and mixed AD (n = 34, 51.5%) were studied. CCM showed a progressive reduction in corneal nerve fiber density (CNFD, fibers/mm²) (32.0±7.5 versus 24.5±9.6 and 20.8±9.3, p < 0.0001), branch density (CNBD, branches/mm²) (90.9±46.5 versus 59.3±35.7 and 53.9±38.7, p < 0.0001), and fiber length (CNFL, mm/mm²) (22.9±6.1 versus 17.2±6.5 and 15.8±7.4, p < 0.0001) in subjects with MCI and dementia compared to NCI. The area under the ROC curve (95% CI) for the diagnostic accuracy of CNFD, CNBD, CNFL compared to MTA-right and MTA-left for MCI was 78% (67–90%), 82% (72–92%), 86% (77–95%) versus 53% (36–69%) and 40% (25–55%), respectively, and for dementia it was 85% (76–94%), 84% (75–93%), 85% (76–94%) versus 86% (76–96%) and 82% (72–92%), respectively.

Conclusion:

The diagnostic accuracy of CCM, a non-invasive ophthalmic biomarker of neurodegeneration, was high and comparable with MTA rating for dementia but was superior to MTA rating for MCI.

Vitamin D3 Dose Requirement That Raises 25-Hydroxyvitamin D to Desirable Level in Overweight and Obese Elderly

CONTEXT

Guidelines for the dosage of vitamin D supplementation vary widely globally.

OBJECTIVE

To investigate the impact of 2 vitamin D doses, bracketed between the IOM recommended dietary allowance (RDA) and the upper tolerable limit, on vitamin D nutritional status in elderly individuals.

METHODS

This post hoc analysis of data collected from a 12-month, double-blind, randomized control trial included 221 ambulatory participants (≥ 65 years) with a mean BMI of 30.2 kg/m2 and a mean baseline serum 25-hydroxyvitamin D [25(OH)D] level of 20.4 ± 7.4 ng/mL, who were recruited from 3 outpatient centers in Lebanon. All participants received 1000 mg of elemental calcium daily from calcium citrate plus the daily equivalent of either 600 IU or 3750 IU of vitamin D3.

RESULTS

Mean 25(OH)D level at 12 months was 26.0 ng/mL with low dose and 36.0 ng/mL with high dose vitamin D3. The proportion of participants reaching a value ≥ 20 ng/mL was 86% in the low dose, and 99% in the high dose arms, with no gender differences. The increment of 25(OH)D per 100 IU/day was 1 ng/mL with the low dose, and 0.41 ng/mL with the high dose. Serum 25(OH)D levels at 1 year were highly variable in both treatment arms. Baseline 25(OH)D level and vitamin D dose-but not age, BMI, gender, or season-were significant predictors of serum 25(OH)D level post-intervention.

CONCLUSION

The IOM Recommended Dietary Allowance (RDA) of 600 IU/day does not bring 97.5% of ambulatory elderly individuals above the desirable threshold of 20 ng/mL. Country-specific RDAs are best derived taking into account the observed variability and predictors of achieved 25(OH)D levels.

Exploring the Role of Community Pharmacists in Obesity and Weight Management in Qatar: A Mixed-Methods Study

Introduction

Obesity is a major public health burden in Qatar. Pharmacists can play an important role in providing weight management services (WMSs). This study aimed to explore their attitudes, practice, perceived competence, and role in WMSs in Qatar.

Methods

A mixed-method explanatory sequential design was applied in the study. A validated online questionnaire was administered followed by qualitative individual and focus group interviews.

Results

Two-hundred seventy community pharmacists completed the survey (response rate 45%). More than half of them indicated that they often or always explain to patients the risks associated with overweight and obesity (56.2%), recommend weight loss medications, herbs or dietary supplements (52.4%), and counsel about their proper use and/or side effects (56.9%). Conversely, the majority of the pharmacists rarely or never measure patients’ waist circumference (83.8%) or calculate their body mass index (72.1%). Over 80% had very positive attitudes towards their role in weight management. Around three-quarters of the participants agreed or strongly agreed that difficulty in following-up with patients (80.7%), lack of private consultation area (75.7%), and lack of pharmacist’s time (75.2%) are barriers for implementing WMSs. More than 60% stated that they are fully competent in 7 out of 24 WMSs listed. Some themes generated include pharmacist’s role and impact in weight management, need for training about weight management, and impact of social media on patients’ perceptions.

Conclusion

Qatar community pharmacists reported positive attitudes towards the provision of WMSs. However, they identified several barriers against provision of WMSs. Several strategies are proposed to overcome barriers and to improve the provision of WMSs in community pharmacies in Qatar.

Association of Cerebral Ischemia With Corneal Nerve Loss and Brain Atrophy in MCI and Dementia

Introduction

This study assessed the association of cerebral ischemia with neurodegeneration in mild cognitive impairment (MCI) and dementia.

Methods

Subjects with MCI, dementia and controls underwent assessment of cognitive function, severity of brain ischemia, MRI brain volumetry and corneal confocal microscopy.

Results

Of 63 subjects with MCI (n = 44) and dementia (n = 19), 11 had no ischemia, 32 had subcortical ischemia and 20 had both subcortical and cortical ischemia. Brain volume and corneal nerve measures were comparable between subjects with subcortical ischemia and no ischemia. However, subjects with subcortical and cortical ischemia had a lower hippocampal volume (P < 0.01), corneal nerve fiber length (P < 0.05) and larger ventricular volume (P < 0.05) compared to those with subcortical ischemia and lower corneal nerve fiber density (P < 0.05) compared to those without ischemia.

Discussion

Cerebral ischemia was associated with cognitive impairment, brain atrophy and corneal nerve loss in MCI and dementia.

Corneal Confocal Microscopy Identifies Parkinson's Disease with More Rapid Motor Progression

BACKGROUND

Corneal confocal microscopy (CCM) is a noninvasive, reproducible ophthalmic technique to quantify corneal small nerve fiber degeneration. CCM demonstrates small nerve fiber damage in Parkinson's disease (PD), but its role as a longitudinal biomarker of PD progression has not been explored.

OBJECTIVE

The aim of this study was to assess corneal nerve morphology using CCM in relation to disease progression in PD.

METHODS

Sixty-four participants with PD were assessed at baseline and at 12-month follow-up. Participants underwent CCM with automated corneal nerve quantification and assessment of Movement Disorder Society Unified Parkinson's Disease Rating Scale, Hoehn and Yahr stage, and Montreal Cognitive Assessment.

RESULTS

Corneal nerve fiber density (CNFD), corneal nerve branch density, corneal nerve fiber length, corneal total branch density, and corneal nerve fiber area were significantly lower in participants with PD compared with healthy control subjects. Worsening of Movement Disorder Society Unified Parkinson's Disease Rating Scale part III score over 12 months was significantly greater in participants with a CNFD in the lowest compared with the highest quartile at baseline (mean difference: 6.0; 95% CI: 1.0-10.9; P = 0.019). There were no significant changes in CNFD, corneal nerve branch density, corneal nerve fiber length, corneal total branch density, corneal nerve fiber area, or corneal nerve fiber width between baseline and 12-month follow-up.

CONCLUSIONS

CCM identifies neurodegeneration in patients with PD, especially those who show the greatest progression in neurological disability. CCM may be a useful tool to help enrich clinical trials with those likely to exhibit more rapid progression and reduce required sample size and cost of studies. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

No Association Between Suicidality and Weight Among School-Attending Adolescents in the United Arab Emirates

Previous data on the link between weight and suicidality is heterogenous. We aim to investigate the potential association between weight and suicidality among adolescents in the United Arab Emirates (UAE). We hypothesize that an association exists between weight and suicidality, with those at both extremes of weight suffering higher rates of suicidal ideation, planning and attempts. The 2016 UAE Global School Health Survey (GSHS) was used. Weight categories based on the World Health Organization Body Mass Index charts were generated. Suicidality measures were based on questions on suicide ideation, planning, and attempt. Univariate and multivariate binary logistic regression were used. Overall, 3.6, 21.4, and 17.5% of students were found to be underweight, overweight, and obese, respectively. In total, 492 students (14.6%) reported suicidal ideation, 397 (11.8%) reported planning, and 389 (11.4%) reported attempts within the twelve months prior to the survey. In the multivariate logistic regression, being female, older, and of lower socioeconomic status were significantly associated with increased suicidal ideation, planning and attempts. Increased parental involvement was associated with decreased suicidality. The association between weight category and suicidality did not reach statistical significance. A significant proportion of Emirati teens are under- or over-weight, with one in seven and one in nine having considered or attempted suicide, respectively. However, this study finds no significant association between weight and suicide ideation, planning, or attempts. This may be due to cultural differences in weight perception. Further research into this association can aid in tailoring suicide prevention interventions.

Correction to: Examining aptitude and barriers to evidence-based medicine among trainees at an ACGME-I accredited program

An amendment to this paper has been published and can be accessed via the original article.

Examining aptitude and barriers to evidence-based medicine among trainees at an ACGME-I accredited program

BACKGROUND

The aims of Evidence-Based medicine (EBM) are to promote critical thinking and produces better patients' outcome (Profetto-McGrath J, J Prof Nurs Off J Am Assoc Coll Nurs 21:364-371, 2005). Accreditation Council for Graduate Medical Education (ACGME) competencies require trainees to locate, appraise and apply clinical evidence to patients' care. Despite the emphasis that ACGME place on EBM, few organizations provide adequate training in EBM. This is even more critical in regions where medical trainees matriculate from diverse backgrounds of undergraduate medical education, where EBM may not be emphasized nor taught at all. EBM practice has a history of research in the West, however, EBM has not been widely studied in the Middle East.

METHODS

Clinicians and trainees at Hamad Medical Corporation (HMC) matriculate from many countries in the Middle East and North Africa (MENA) and Asia. Because trainees in Graduate Medical Education (GME) come to HMC from a variety of geographic backgrounds, it is assumed that they also have a variety of experiences and aptitudes in EBM. To assess trainees EBM attitudes and knowledge in the internal medicine department at HMC in Doha, Qatar, the authors surveyed residents and fellows using a two-part survey. The first part was adapted from the evidence-based practice inventory by Kaper to assess trainees' attitudes and perceptions of EBM. Trainees were also asked to complete the Assessing Competency in Evidence Based Medicine (ACE) tool to evaluate their aptitude in different elements of EBM. The results from the two parts were analyzed.

RESULTS

The average score on the ACE tool among the participants was 8.9 (±1.6). Most participants rated themselves as beginners or intermediate in their EBM capabilities. Higher ACE scores were observed from participants with educational background from South Asia, and among those with more favorable attitudes towards EBM. There was no clear pattern that early incorporation of EBM into practice will result in better ACE score. Participants also reported reasonable abilities in EBM tasks and a favorable work atmosphere for EBM implementation. Lack of knowledge, resources, and time were the most reported barriers to utilizing EBM.

CONCLUSIONS

While it is clear that participants are enthusiastic about EBM and see it as a useful method for clinical decision making, their aptitude in EBM is not optimal and there are gaps and barriers for them to practice.

Faculty perceptions of student plagiarism and interventions to tackle it: a multiphase mixed-methods study in Qatar

BACKGROUND

The widespread use of the internet and other digital resources has contributed to the escalation of plagiarism among medical students and students of other healthcare professions. Concerns were raised by faculty at Weill Cornell Medicine-Qatar (WCM-Q), a branch of Weill Cornell Medicine of Cornell University in New York, who had been observing plagiarism in students' assignments.

METHODS

To identify the extent of plagiarism practices and their contributing factors, a two-phase mixed-method research study was conducted, comprising a survey administered in 2013, followed by longitudinal interventions, and a second survey in 2017 to measure the impact of the interventions.

RESULTS

By Phase II, overall observed plagiarism incidents per year decreased from 44 to 28%, and the number of faculty who observed no plagiarism incidents increased significantly from 12 to 37%. The faculty concerned about student plagiarism decreased by 33% [53.1 to 20%] between Phase I and Phase II.

CONCLUSION

When students are provided with information regarding what constitutes plagiarism and their institution's policy in response to plagiarism incidents, they are less likely to engage in such practices.

Prevalence and risk factors for diabetic neuropathy and painful diabetic neuropathy in primary and secondary healthcare in Qatar

Aims/Introduction

This study determined the prevalence and risk factors for diabetic peripheral neuropathy (DPN) and painful DPN (pDPN) in patients with type 2 diabetes in primary healthcare (PHC) and secondary healthcare (SHC) in Qatar.

Materials and Methods

This was a cross‐sectional multicenter study. Adults with type 2 diabetes were randomly enrolled from four PHC centers and two diabetes centers in SHC in Qatar. Participants underwent assessment of clinical and metabolic parameters, DPN and pDPN.

Results

A total of 1,386 individuals with type 2 diabetes (297 from PHC and 1,089 from SHC) were recruited. The prevalence of DPN (14.8% vs 23.9%, P = 0.001) and pDPN (18.1% vs 37.5%, P < 0.0001) was significantly lower in PHC compared with SHC, whereas those with DPN at high risk for diabetic foot ulceration (31.8% vs 40.0%, P = 0.3) was comparable. The prevalence of undiagnosed DPN (79.5% vs 82.3%, P = 0.66) was comparably high, but undiagnosed pDPN (24.1% vs 71.5%, P < 0.0001) was lower in PHC compared with SHC. The odds of DPN and pDPN increased with age and diabetes duration, and DPN increased with poor glycemic control, hyperlipidemia and hypertension, whereas pDPN increased with obesity and reduced physical activity.

Conclusions

The prevalence of DPN and pDPN in type 2 diabetes is lower in PHC compared with SHC, and is attributed to overall better control of risk factors and referral bias due to patients with poorly managed complications being referred to SHC. However, approximately 80% of patients had not been previously diagnosed with DPN in PHC and SHC. Furthermore, we identified a number of modifiable risk factors for PDN and pDPN.

Prevalence and management of diabetic neuropathy in secondary care in Qatar

AIMS

Diabetic neuropathy (DN) is a "Cinderella" complication, particularly in the Middle East. A high prevalence of undiagnosed DN and those at risk of diabetic foot ulceration (DFU) is a major concern. We have determined the prevalence of DN and its risk factors, DFU, and those at risk of DFU in patients with type 2 diabetes mellitus (T2DM) in secondary care in Qatar.

MATERIALS AND METHODS

Adults with T2DM were randomly selected from the two National Diabetes Centers in Qatar. DN was defined by the presence of neuropathic symptoms and a vibration perception threshold (VPT) ≥ 15 V. Participants with a VPT ≥ 25 V were categorized as high risk for DFU. Painful DN was defined by a DN4 score ≥4. Logistic regression analysis was used to identify predictors of DN.

RESULTS

In 1082 adults with T2DM (age 54 ± 11 years, duration of diabetes 10.0 ± 7.7 years, 60.6% males), the prevalence of DN was 23.0% (95% CI, 20.5%-25.5%) of whom 33.7% (95% CI, 27.9%-39.6%) were at high risk of DFU, and 6.3% had DFU; 82.0% of the patients with DN were previously undiagnosed. The prevalence of DN increased with age and duration of diabetes and was associated with poor glycaemic control (HbA_1c  ≥ 9%) AOR = 2.1 (95% CI, 1.3-3.2), hyperlipidaemia AOR = 2.7 (95% CI, 1.5-5.0), and hypertension AOR = 2.0 (95% CI, 1.2-3.4).

CONCLUSIONS

Despite DN affecting 23% of adults with T2DM, 82% had not been previously diagnosed with one-third at high risk for DFU. This argues for annual screening and identification of patients with DN. Furthermore, we identify hyperglycaemia, hyperlipidaemia, and hypertension as predictors of DN.

Effect of gender on childhood maltreatment in the state of Qatar: Retrospective study

BACKGROUND

International maltreatment studies show a range of results for overall rates of child maltreatment and gender differences. The ISPCAN Child Abuse Screening Tools (ICAST) were designed to reduce variability in data collection.

OBJECTIVE

To investigate the influence of gender on the experiences of discipline and maltreatment in childhood among young people in Qatar, informingpractice and policy development.

PARTICIPANTS AND SETTING

A representative sample of Qatari youth aged between 18 and 24 years were identified using a cross sectional random household survey. The total number of subjects was 697 of whom 46.8% were male.

METHODS

Participants self-administered the ICAST-R (retrospective), which includes questions about exposure below the age of 18 to potentially abusive physical, psychological and sexual behaviors. Verbal consent was obtained following an introductory explanation and assurance ofconfidentiality.

RESULTS

At least one form of physical abuse was reported by 22.1% of participants and was significantly higher among males (28.2%) than females (16.7%) p<0.001). A trend for greater abuse was identified among boys aged over five which become statistically significant between 10 -13 years (p=0.001). For psychological abuse the overall rates were very similar, 16.2% for girls and 15.0% for boys. Only 17 (2.5%) of participants reported sexual abuse, with no statistically significant gender difference.

CONCLUSIONS

Physical, psychological and sexual abuse all occur in Qatar. This study demonstrates the importance of identifying the role of gender and age when exploring the extent and nature of maltreatment in a population. It allows for better targeting of preventative action.

Prevalence and risk factors for painful diabetic neuropathy in secondary healthcare in Qatar

AIMS/INTRODUCTION

Painful diabetic peripheral neuropathy (PDPN) has a significant impact on the patient's quality of life. The prevalence of PDPN in the Middle East and North Africa region has been reported to be almost double that of populations in the UK. We sought to determine the prevalence of PDPN and its associated factors in type 2 diabetes mellitus patients attending secondary care in Qatar.

MATERIALS AND METHODS

This was a cross-sectional study of 1,095 participants with type 2 diabetes mellitus attending Qatar's two national diabetes centers. PDPN and impaired vibration perception on the pulp of the large toes were assessed using the Douleur Neuropathique en 4 questionnaire with a cut-off ≥4 and the neurothesiometer with a cut-off ≥15 V, respectively.

RESULTS

The prevalence of PDPN was 34.5% (95% confidence interval [CI] 31.7-37.3), but 80% of these patients had not previously been diagnosed or treated for this condition. Arabs had a higher prevalence of PDPN compared with South Asians (P < 0.05). PDPN was associated with impaired vibration perception adjusted odds ratio (AOR) 4.42 (95% CI 2.92-6.70), smoking AOR 2.43 (95% CI 1.43-4.15), obesity AOR 1.74 (95% CI 1.13-2.66), being female AOR 1.65 (95% CI: 1.03-2.64) and duration of diabetes AOR 1.08 (95% CI 1.05-1.11). Age, poor glycemic control, hypertension, physical activity and proteinuria showed no association with PDPN.

CONCLUSIONS

PDPN occurs in one-third of type 2 diabetes mellitus patients attending secondary care in Qatar, but the majority have not been diagnosed. Arabs are at higher risk for PDPN. Impaired vibration perception, obesity and smoking are associated with PDPN in Qatar.

Hypertension Contributes to Neuropathy in Patients With Type 1 Diabetes

BACKGROUND

Diabetic peripheral neuropathy (DPN) can lead to foot ulceration and amputation. There are currently no disease-modifying therapies for DPN. The aim of this study was to determine if hypertension contributes to DPN in patients with type 1 diabetes mellitus (T1DM).

METHODS

Subjects with T1DM (n = 70) and controls (n = 78) underwent a comprehensive assessment of DPN.

RESULTS

Hypertension was present in 40 of 70 T1DM subjects and 20 of 78 controls. Hypertension was associated with abnormal nerve conduction parameters (P = 0.03 to <0.001), increased vibration perception threshold (P = 0.01) and reduced corneal nerve fiber density and length (P = 0.02) in subjects with T1DM. However, after adjusting for confounding factors only tibial compound motor action potential and nerve conduction velocity were associated with hypertension (P = 0.03) and systolic blood pressure (P < 0.01 to <0.0001). Hypertension had no effect on neuropathy in subjects without diabetes.

CONCLUSIONS

This study shows that hypertension is associated with impaired nerve conduction in T1DM. It supports previous small trials showing that angiotensin-converting enzyme inhibitors improve nerve conduction and advocates the need for larger clinical trials with blood pressure lowering agents in DPN.

Association of corneal nerve fiber measures with cognitive function in dementia

Objectives

Corneal confocal microscopy (CCM) is a noninvasive ophthalmic technique that identifies corneal nerve degeneration in a range of peripheral neuropathies and in patients with multiple sclerosis, Parkinson's disease, and amyotrophic lateral sclerosis. We sought to determine whether there is any association of corneal nerve fiber measures with cognitive function and functional independence in patients with MCI and dementia.

Methods

In this study, 76 nondiabetic participants with MCI (n = 30), dementia (n = 26), and healthy age‐matched controls (n = 20) underwent assessment of cognitive and physical function and CCM.

Results

There was a progressive reduction in corneal nerve fiber density (CNFD), branch density (CNBD), and fiber length (CNFL) (P < 0.0001) in patients with MCI and dementia compared to healthy controls. Adjusted for confounders, all three corneal nerve fiber measures were significantly associated with cognitive function (P < 0.05) and functional independence (P < 0.01) in MCI and dementia. The area under the ROC curve to distinguish MCI with CNFD, CNBD, and CNFL was 69.1%, 73.2%, and 73.0% and for dementia it was 84.8%, 84.2%, and 86.2%, respectively.

Interpretation

CCM demonstrates corneal nerve fiber loss, which is associated with a decline in cognitive function and functional independence in patients with MCI and dementia.

Evaluation of an intensive education program on the treatment of tobacco-use disorder for pharmacists: a study protocol for a randomized controlled trial

BACKGROUND

Tobacco use is presently responsible for the death of over seven million people across the world. In Qatar, it is one of the main causes of premature deaths and preventable diseases. To reduce tobacco use, Qatar has ratified the World Health Organization (WHO)'s Framework Convention on Tobacco Control (FCTC) and has implemented many tobacco-control initiatives. In spite of these measures, tobacco use is still considered a public health threat in Qatar. Pharmacists practicing in retail/community pharmacy settings are often the first port of call for individuals requiring general health advice. Evidence has proven that they have a pivotal role in health promotion and disease prevention including tobacco cessation. However, pharmacists in Qatar are not actively involved in tobacco control and many have not received any education or training about smoking cessation counseling in the past. In an effort to build the capacity of pharmacists towards tobacco control in Qatar, the aim of the proposed study is to design, implement, and evaluate an intensive education program on tobacco dependence treatment for pharmacists in Qatar.

METHODS/DESIGN

The study will be a prospective randomized controlled trial comparing an intensive tobacco-related education program versus non-tobacco-related training on pharmacists' tobacco-use-related knowledge, attitudes, self-efficacy, and skills. Community pharmacists practicing in Qatar will be eligible for participation in the study. A random sample of pharmacists will be selected for participation. Consenting participants will be randomly allocated to intervention or control groups. Participants in the intervention group will receive an intensive education program delivered by a multi-disciplinary group of educators, researchers, and clinicians with expertise in tobacco cessation. A short didactic session on a non-tobacco-related topic will be delivered to pharmacists in the control group. The study has two primary outcomes: post-intervention tobacco-related knowledge and post-intervention skills for tobacco cessation assessed using a multiple-choice-based evaluation instrument and an Objective Structured Clinical Examination (OSCE), respectively. The secondary study outcomes are post-intervention attitudes towards tobacco cessation and self-efficacy in tobacco-cessation interventions assessed using a survey instrument. An additional secondary study outcome is the post-intervention performance difference in relation to tobacco-cessation skills in the practice setting assessed using the simulated client approach.

DISCUSSION

If demonstrated to be effective, this education program will be considered as a model that Qatar and the Middle East region can apply to overcome the burden of tobacco-use disorder.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03518476 . Registered on 8 May 2018. Version 1/22 June 2018.

Epidemiology and treatment patterns of rheumatoid arthritis in a large cohort of Arab patients

OBJECTIVES

There is limited information on the epidemiology and treatment patterns of rheumatoid arthritis (RA) across the Arab region. We aim in this study to describe the demographic characteristics, clinical profile, and treatment patterns of patients of Arab ancestry with RA.

METHODS

This is a cross sectional study of 895 patients with established rheumatoid arthritis enrolled from five sites (Jordan, Lebanon, Qatar, Kingdom of Saudi Arabia (KSA), and United Arab Emirates). Demographic characteristics, clinical profile, and treatment patterns are compared between the five countries.

RESULTS

The majority of our patients are women, have an average disease duration of 10 years, are married and non-smokers, with completed secondary education. We report a high (>80%) ever-use of methotrexate (MTX) and steroids among our RA population, while the ever-use of disease modifying anti-rheumatic drugs (DMARDs) and TNF-inhibitors average around 67% and 33%, respectively. There are variations in RA treatment use between the five country sites. Highest utilization of steroids is identified in Jordan and KSA (p-value < 0.001), while the highest ever-use of TNF-inhibitors is reported in KSA (p-value < 0.001).

CONCLUSION

Disparities in usage of RA treatments among Arab patients are noted across the five countries. National gross domestic product (GDP), as well as some other unique features in each country likely affect these. Developing treatment guidelines specific to this region could contribute in delivering standardized therapies to RA patients.

The educational preparation of nurses in a developing economy and patient mortality

BACKGROUND

Most studies have reported that higher levels (baccalaureate degree) of educational attainment by nurses are associated with lower levels of patient mortality. Researchers working in developed economies (e.g. North America and Europe) have almost exclusively conducted these studies. The value of baccalaureate nurse education has not been tested in countries with a developing economy.

METHOD

A retrospective observational study conducted in seven hospitals. Patient mortality was the main outcome of interest. Anonymized data were extracted from nurses and patients from two different administrative sources and linked using the staff identification number that exists in both systems. We used bivariate logistic regression models to test the association between mortality and the educational attainment of the admitting nurse (responsible for assessment and care planning).

RESULTS

Data were extracted for 11 918 (12, 830 admissions) patients and 7415 nurses over the first 6 months of 2015. The majority of nurses were educated in South Asia and just over half were educated to at least bachelor degree level. After adjusting for confounding and clustering, nurse education was not found to be associated with mortality.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Our observations may suggest that in a developing economy, the academic level of nurses' education is not associated with a reduction in patient mortality. Findings should be interpreted with considerable caution but do challenge widely held assumptions about the value of baccalaureate-prepared nurses. Further research focused on nursing education in developing economies is required to inform health policy and planning.

Utilization of Evidence-Based Secondary Prevention Medications at the Time of Discharge in Patients with Acute Coronary Syndrome (ACS) in Qatar

BACKGROUND AND OBJECTIVES

In Qatar, ACS (Acute Coronary Syndrome) has become the leading cause of morbidity and mortality. Guidelines recommend that ACS patients should receive indefinite treatment with antiplatelets, β-blockers, angiotensin converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) and statins. The study objectives were to assess the use of evidence-based secondary prevention medication at discharge among ACS patients in Qatar and to determine the clinical and demographic characteristics associated with the use of these medications.

SETTING AND METHODS

A retrospective medical record review was conducted at the Heart Hospital in Qatar. A random sample of 1068 ACS patients was selected. Patient characteristics were summarized. Prevalence of medications at discharge were computed for each medication as well as for medication combinations. Multiple logistic regression was used to detect patient variables that were associated with the outcomes. A p≤0.05 was considered significant.

MAIN OUTCOME MEASURES

-Percentage of ACS patients discharged on each of the following medications: antiplatelets (aspirin, clopidogrel), β-blockers, ACEI or ARBs and statins and on the combination of these medications-Association between the use of these medications and patient characteristics.

RESULTS

In total, 1064 records were reviewed. The majority were males (85.3%) and about 1 in 5 (18.7%) were Qatari. At discharge, patients were prescribed the following: aspirin (96.0%), clopidogrel (92.0%), β-blockers (90.6%) and statins (97.7%). ACEI and ARBs were prescribed to 63.5 and 11.3%, respectively. The concurrent 4 medications (aspirin or clopidogrel, statins or other lowering cholesterol medication, β-blockers and ACEI or ARB) were prescribed to 773 patients (77.8%; 95% confidence interval: 75.2-80.4%). Being overweight or obese, and having PCI (percutaneous coronary intervention) or hypertension were associated with higher prescription of the concurrent medications. Those with diabetes had a 52% increase in the odds of prescribing the 4 medications. Those with kidney disease had a 67% reduction in the odds of prescribing.

CONCLUSION

Most ACS patients were prescribed antiplatelets, β-blockers and statins, but the use of ACEIs or ARBs was suboptimal. Strategies are needed to enhance ACEI or ARB prescribing, especially for high risk patients who would have the greatest therapeutic benefit from these drugs.

Effectiveness of a pharmacist-delivered smoking cessation program in the State of Qatar: a randomized controlled trial

Background

Cigarette smoking is one of the major preventable causes of death and diseases in Qatar. The study objective was to test the effect of a structured smoking cessation program delivered by trained pharmacists on smoking cessation rates in Qatar.

Methods

A prospective randomized controlled trial was conducted in eight ambulatory pharmacies in Qatar. Eligible participants were smokers 18 years and older who smoked one or more cigarettes daily for 7 days, were motivated to quit, able to communicate in Arabic or English, and attend the program sessions. Intervention group participants met with the pharmacists four times at 2 to 4 week intervals. Participants in the control group received unstructured brief smoking cessation counseling. The primary study outcome was self-reported continuous abstinence at 12 months. Analysis was made utilizing data from only those who responded and also using intent-to-treat principle. A multinomial logistic regression model was fitted to assess the predictors of smoking at 12 months. Analysis was conducted using IBM-SPSS® version 23 and STATA® version 12.

Results

A total of 314 smokers were randomized into two groups: intervention (n = 167) and control (n = 147). Smoking cessation rates were higher in the intervention group at 12 months; however this difference was not statistically significant (23.9% vs. 16.9% p = 0.257). Similar results were observed but with smaller differences in the intent to treat analysis (12.6% vs. 9.5%, p = 0.391). Nevertheless, the daily number of cigarettes smoked for those who relapsed was significantly lower (by 4.7 and 5.6 cigarettes at 3 and 6 months respectively) in the intervention group as compared to the control group (p = 0.041 and p = 0.018 respectively). At 12 months, the difference was 3.2 cigarettes in favor of the intervention group but was not statistically significant (p = 0.246). Years of smoking and daily number of cigarettes were the only predictors of smoking as opposed to quitting at 12 months (p = 0.005; p = 0.027 respectively).

Conclusions

There was no statistically significant difference in the smoking cessation rate at 12 months between the groups. However, the smoking cessation program led to higher (albeit non-significant) smoking cessation rates compared with usual care. More research should be conducted to identify factors that might improve abstinence.

Trial registration

Clinical Trials NCT02123329. Registration date 20 April 2014

The effect of Nurse GraduaTeness on patient mortality: a cross-sectional survey (the NuGaT study)

AIM

To investigate the relationship between patient mortality and the educational preparation (graduateness) of the nurses who cared for them.

BACKGROUND

There have been 18 studies over the last two decades examining the effect of nurses' educational qualifications on mortality. All but three have used mortality data aggregated at the hospital level that has been combined with surveys of nurses to estimate the level of graduateness in the population. Data collection and extraction generally has been done at different points in time.

DESIGN

A retrospective, cross-sectional study.

METHOD

Routine administrative patient data were extracted (May-August 2015). The primary outcome was all-cause patient mortality at discharge. We were able to identify the individual nurses who provided care during patients inpatient stay using an identification number. We were then able to calculate the 'graduateness' of the nursing care patients received by dividing the number of recorded episodes of care provided by baccalaureate prepared nurses with the total number of care episodes.

RESULTS

After adjusting for confounding, we observed a significant association between patient mortality and nurse graduateness. Our observations suggest an optimum level of baccalaureate prepared nurses of approximately 70%. Above this level, there appears to be no additional decrease in mortality rates.

CONCLUSION

This study represents an important methodological step forward over previous approaches. Our observations are generally consistent with existing literature and confirm the importance of baccalaureate nurse education.

Role of pharmacist in cardiovascular disease-related health promotion and in hypertension and dyslipidemia management: a cross-sectional study in the State of Qatar

RATIONALE, AIMS AND OBJECTIVES

In Qatar, cardiovascular diseases (CVD) have recently become the leading cause of morbidity and mortality. Prevention, detection and management of CVD risk factors reduce CVD chance. The study objectives were to assess Qatar pharmacists' involvement in CVD health promotion, to identify the activities that they currently provide to patients with CVD risk factors, to describe their attitudes towards their involvement in CVD prevention and to assess their perceived barriers for provision of CVD prevention services

METHOD

We conducted a cross-sectional survey of community and ambulatory pharmacists in Qatar. Pharmacist characteristics, involvement in CVD-related activities along with their attitudes and perceived barriers were analysed using frequency distributions. Bivariate linear regression models were used to test for associations between CVD health promotion activity score and each variable. Variables with a P-value of 0.20 or less were included in the multivariate model.

RESULTS

A total of 141 pharmacists completed the survey (response rate 60%). More than 70% responded with rarely or never to 6 out of the 10 CVD health promotion activities. Eighty-four per cent and 68% always or often describe to patients the appropriate time to take antihypertensive medications and the common medication adverse effects, respectively. Yet, 50% rarely or never review the medication refill history or provide adherence interventions. Lack of CVD educational materials was the top perceived barrier (55%) in addition to lack of having private counselling area (44.6%), and lack of time (38.3%). Females and community pharmacists were more involved in CVD health promotion (P = 0.046 and P = 0.017, respectively) than their counterparts. Health promotion practice increased with increasing attitudes score and decreased with increased barriers score (P = 0.012 and P = 0.001).

CONCLUSION

The scope of pharmacy practice in CVD prevention is limited in Qatar. Efforts need to be exerted to increase pharmacists' involvement in CVD prevention.

Seat belt and mobile phone use among vehicle drivers in the city of Doha, Qatar: an observational study

BACKGROUND

In Qatar traffic injuries and fatalities are of serious concern. Mobile phone use whilst driving has been associated with increased risk of vehicular collisions and injuries. Seat belt use has been demonstrated to save lives and reduce the severity of road traffic injuries. Whereas previously published studies may have looked at all front passengers, this study aims to obtain reliable estimates of the prevalence of seat belt and mobile phone use among vehicle drivers in the city of Doha, Qatar. Additionally, we aim to investigate the association of these behaviors with other variables namely gender, time of the day and type of vehicle.

METHODS

An observational study on 2,011 vehicles was conducted in 2013. Data were collected at ten sites within Doha city over a two-week period. Two trained observers surveyed each car and recorded observations on a data collection form adapted from a form used in a 2012 Oklahoma observational study. Associations were assessed using the Chi-squared test or Fisher's exact test. A p-value of .05 or less was considered statistically significant.

RESULTS

Overall, 1,463 (72.7 %) drivers were found using a seat belt (95 % CI: 70.8-74.7 %) and 150 (7.5 %) their mobile phones (95 % CI: 6.3-8.6 %) during the observation period. Mobile phone use was significantly associated with not using a seat belt and driving a sport utility vehicle. Significantly lower rates of seat belt use were observed in the early morning and late afternoon. No gender differences were observed.

DISCUSSION

Seatbelt use in Doha was found to be similar to countries in the region but lower than those in western countries. Also, studies from other high-income locations, reported lower rates of mobile phone use while driving than in Doha.

CONCLUSIONS

Despite road traffic crashes being one of the leading causes of death in Qatar, three out of 10 drivers in Doha, Qatar, do not use a seat belt and about one in 12 use a mobile phone while driving. More efforts, in the form of awareness campaigns and increased law enforcement, are needed to improve compliance with laws requiring seat belt use and prohibiting mobile phone use while driving.

Assessing the effectiveness of a pharmacist-delivered smoking cessation program in the State of Qatar: study protocol for a randomized controlled trial

BACKGROUND

It had been reported that up to 37% of the adult male population smokes cigarettes in Qatar. The Global Youth Tobacco Survey also stated that 13.4% of male school students aged 13 to 15 years in Qatar smoke cigarettes. Smoking cessation is key to reducing smoking-related diseases and deaths. Healthcare providers are in an ideal position to encourage smoking cessation. Pharmacists are the most accessible healthcare providers and are uniquely situated to initiate behavior change among patients. Many studies have shown that pharmacists can be successful in helping patients quit smoking. Studies demonstrating the effectiveness of pharmacist-delivered smoking cessation programs are lacking in Qatar. This proposal aims to test the effect of a structured smoking cessation program delivered by trained ambulatory pharmacists in Qatar.

METHODS/DESIGN

A prospective, randomized, controlled trial is conducted at eight ambulatory pharmacies in Qatar. Participants are randomly assigned to receive an at least four-session face-to-face structured patient-specific smoking cessation program conducted by the pharmacist or 5 to 10 min of unstructured brief smoking cessation advice (emulating current practice) given by the pharmacist. Both groups are offered nicotine replacement therapy if feasible. The primary outcome of smoking cessation will be confirmed by an exhaled carbon monoxide test at 12 months. Secondary outcomes constitute quality-of-life adjustment as well as cost analysis of program resources consumed, including per case and patient outcome.

DISCUSSION

If proven to be effective, this smoking cessation program will be considered as a model that Qatar and the region can apply to decrease the smoking burden.

TRIAL REGISTRATION

Clinical Trials NCT02123329 .

Challenges to obtaining parental permission for child participation in a school-based waterpipe tobacco smoking prevention intervention in Qatar

BACKGROUND

Involving children in research studies requires obtaining parental permission. A school-based intervention to delay/prevent waterpipe use for 7th and 8th graders in Qatar was developed, and parental permission requested. Fifty three percent (2308/4314) of the parents returned permission forms; of those 19.5% of the total (840/4314) granted permission. This paper describes the challenges to obtaining parental permission. No research to date has described such challenges in the Arab world.

METHODS

A random sample of 40 schools in Doha, Qatar was selected for inclusion in the original intervention. Permission forms were distributed to parents for approval of their child's participation. The permission forms requested that parents indicate their reasons for non-permission if they declined. These were categorized into themes. In order to understand reasons for non-permission, interviews with parents were conducted. Phone numbers of parents were requested from the school administration; 12 of the 40 schools (30%) agreed to provide the contact information. A random sample of 28 parents from 12 schools was interviewed to reach data saturation. Thematic analysis was used to analyze their responses.

RESULTS

Reasons for non-permission documented in both the forms and interviews included: poor timing; lack of interest; the child not wanting to participate; and the child living in a smoke-free environment. Interviews provided information on important topics to include in the consent forms, parents' decision-making processes regarding their child's participation, and considerations for communicating with parents. Many parents also indicated that this was the first time they had been asked to give an informed consent for their child's participation in a study.

CONCLUSIONS

Results indicate that more attention needs to be given to the informed parental consent process. Researchers should consider enhancing both the methods of communicating information as well the specific information provided. Before embarking on recruitment of children for studies, formative research on the parental consent process is suggested.

Macular ultrastructural features in amblyopia using high-definition optical coherence tomography

PURPOSE

To study macular morphology in amblyopic eyes using high-definition spectral domain optical coherence tomography (SD-OCT) and to compare the findings with fellow eyes.

METHODS

This was a prospective institutional study of patients ≥6 years of age with unilateral amblyopia. Enhanced high-definition single line macular scans of amblyopic eyes were obtained using SD-OCT and compared with fellow eyes. Scans were evaluated qualitatively for structural differences. Central foveal thickness was measured and areas of the different retinal layers were computed within 500 µm from the foveal centre nasally and temporally.

RESULTS

Forty-five patients with unilateral amblyopia were included: 25 with strabismic and 20 with anisometropic amblyopia with a mean age of 24.8 years. Qualitatively, the bulge in the inner segment/outer segment junction of the central fovea was noted to be attenuated or absent in 60% of amblyopic eyes compared with 29% of normal eyes, p=0.02. Also, amblyopic eyes demonstrated a shallow foveal pit compared with normal fellow eyes. Mean foveal thickness was significantly increased in amblyopic (228.56 µm) versus fellow eyes (221.72 µm), p=0.03. Upon exploring different retinal layers, the temporal inner nuclear layer area was increased (p=0.04) while the outer nuclear layer area was decreased (p=0.04) in amblyopic eyes compared with fellow eyes.

CONCLUSIONS

Using enhanced high-definition SD-OCT, amblyopic eyes demonstrated qualitative and quantitative differences in macular features, possibly representing signs of immaturity compared with normal fellow eyes.